All prospective employees will receive consideration without discrimination because of race, color, creed, age, natural origin or handicap. All information provided herein will be kept confidential.

APPLICANT

Last Name First Middle *

Date *

Street Address *

Home Phone *

City State Zip Code *

Business Phone *

Social Security Number *

Emergency contact (person not living with you)

Have you ever applied for employment with this Agency?

YesNo

How many hours a week are you available for work?

Are you legally eligible for employment in the United States?

YesNo

How did you learn of our organization?

Newspaper Ad

Friend

Other

Are you willing to work on evenings/weekends: If so, what hours?

Position applying for

EDUCATION

School Name of Degree/Diploma

Location of School

Course of Study

Years

College

Vo-Tech or Trade

High School

Other

EMPLOYMENT

List the last five years employment history, starting with the most recent employer.

1. Company Name

Telephone

Address

Dates of Employment

From

To

City

State

Zip Code

Starting Pay

Job Title and describe your work

Reason for leaving

2. Company Name

Telephone

Address

Dates of Employment

From

To

City

State

Zip Code

Starting Pay

Job Title and describe your work

Reason for leaving

3. Company Name

Telephone

Address

Dates of Employment

From

To

City

State

Zip Code

Starting Pay

Job Title and describe your work

Reason for leaving

Was your last name different from your present name during the above listed jobs?

YesNo

If Yes, what was your name?

Are you currently employed?

YesNo

Do you have reliable transportation?

YesNo

PROFESSIONAL REFERENCES

Persons who can furnish information about job performance

1. Name

Telephone

Address

2. Name

Telephone

Address

3. Name

Telephone

Address

GENERAL

Have you ever been convicted of a crime in the past 5 years, barring employment in a Home Care and community support Agency?

YesNo

Conviction will not necessarily disqualify an applicant from employment. If yes, describe in full

Are you capable of performing the job set forth in the job description?

YesNo

If you answered No, which job requirement can you not meet?

CREDENTIALS/SPECIALIZED SKILLS & QUALIFICATIONS/EQUIPMENT OPERATED

List all states in which licensed giving registration and expiration date. Summarize special job-related skills and qualification acquired from employment or other experience.

*I certify that the facts contained in this application are true and complete to the best of my knowledge and understand, that, if employed, falsified statements on this application SHALL BE GROUNDS FOR DISMISSAL

*I Authorize complete investigation of all statements contained herein and herby give my full permission for the Agency to contact and fully discuss my background and history with all persons and entities listed above to give the Agency any and all information concerning my previous employment and any information they may have, and release all former employees and others listed above from all liability for any damage that my result from furnishing the same to the Agency.

*I understand and agree that, if hired, my employment is for no definite period arid may, regardless of the date of payment of my wages and salary, be terminated at any time for any lawful reason, without prior notice and with or without cause.

*This application for employment shall be considered active for a period of time not to exceed 45 days. Any applicant wishing to be considered for employment beyond this time period shall inquire as to whether or not applications are being accepted at that time.